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   Table of Contents - Current issue
Coverpage
July-December 2019
Volume 6 | Issue 2
Page Nos. 65-130

Online since Wednesday, August 7, 2019

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STATE OF THE ART  

Management of velopharyngeal insufficiency: The evolution of care and the current state of the art p. 65
Ann W Kummer
DOI:10.4103/jclpca.jclpca_10_19  
Velopharyngeal insufficiency (VPI) is a condition in which there is incomplete closure of the velopharyngeal valve during speech production. This results in hypernasality and/or audible nasal emission. Nasal emission can cause additional secondary characteristics, including weak or omitted consonants, compensatory articulation productions, short utterance length, and even dysphonia. Overall, this condition affects the quality and intelligibility of speech production, which can have a significant effect on the individual's communication and social interactions. This article provides a brief overview of how the management of VPI has evolved over the past 40 years (which is the extent of this author's career). In addition, the current state of the art in VPI management is discussed from this author's perspective. Finally, a pathway is suggested for the future evolution of care for patients affected by VPI.
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ORIGINAL ARTICLES Top

A comprehensive review of orofacial cleft patients at a university hospital genetic department in the UK p. 73
Rajshree Jayarajan, Pradeep Vasudevan
DOI:10.4103/jclpca.jclpca_4_19  
Background: Cleft lip and palate or isolated cleft palate is one of the most common congenital anomalies with a general prevalence of 1 in 700 live births. The aetiology is considered to be a combination of genetic and environmental factors. Clinical genetics service provides information, diagnosis, counselling, management and support to patients and families with genetic disorders. Materials and Methods: Data collection was carried out retrospectively from the Genetics department database. The details regarding referrals, assessment, genetic tests and outcomes were analyzed. Results: There were 33 cases from 2012 to 2016. The majority of cases (61%) were White British. Others included Caribbean, Chinese, Indian, Other Asian, and other mixed categories. 67% of patients had associated other anomalies ranging from being part of a syndrome to separate entities. 36% had family history of clefts and 24% of family members had anomalies other than cleft. Genetic analysis showed abnormality only in 4 of the cases (12%) and 2 had results of unknown significance. Conclusions: Genetic counselling should be built into the plan of cleft care in a structured manner and made available to both patients and parents. There should be a global approach to improve identification and analysis of functional elements controlling gene expression. Integration of genetics and environmental risk using epigenetics is warranted so that aetiology can be better defined and eventual outcome would be more effective clinical care and prevention.
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Columellar strut graft in unilateral cleft nasal deformity: Anthropometry and clinical outcomes p. 84
Kumar Prasad Preetha Rani, Atul Parashar, Ramesh Kumar Sharma
DOI:10.4103/jclpca.jclpca_2_19  
Introduction: The cleft nasal deformity is a three-dimensional asymmetry involving all layers of the nose. Columellar strut graft is an important method to provide support to the skeletal framework in an attempt to retain structural support and balance. Aims: The purpose of our study is to describe the surgical outcomes following the use of columellar strut graft when it is used in secondary cleft rhinoplasty. The study was designed to identify the changes in tip projection (Tip Proj), tip rotation (Tip Rot), and other anthropometric measurements postoperatively. Materials and Methods: A prospective study was conducted among patients presenting with secondary cleft nasal deformity and operated utilizing a columellar strut graft. The parameters considered were columellar height (CH), columellar width, Tip Proj, Tip Rot, nasofrontal angle, nasofacial angle, and nasolabial angle. All the measurements were analyzed statistically. Results: During the study, results could be evaluated for 25 patients. The Tip Proj increased in 84% of patients, and the magnitude of difference between pre- and post-operative follow-up at 9 months was found to be statistically significant (P = 0.009). The CH increased in 20 patients (80%). The Tip Rot increased in 20 patients (80%). The postoperative changes were consistently maintained at different follow-up intervals. Conclusions: Columellar strut is necessary in improving the Tip Proj, correcting the tilted tripod and lower lateral cartilage deformities. It also functions as a central scaffold on which the tip structures can be unified.
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Analysis of preoperative measurements in unilateral cleft lip patients toward the outcome of secondary cleft deformities p. 93
Evelyn Yoke Ling Hoh, Wan Azman Wan Sulaiman
DOI:10.4103/jclpca.jclpca_1_19  
Introduction: The purpose of this study is to determine whether the severity of the initial cleft deformity has any effect on the postoperative result of primary lip and palate repair in terms of the presence or severity of secondary deformity. The anthropometric measurements of the cleft side will be measured against the noncleft side as control. Materials and Methods: This was a cross-sectional, noninterventional study conducted for 12 months from March 2017 to March 2018. All children aged 5–12 years old with unilateral cleft lip deformity who underwent cleft lip repair from the year 2005 to 2013 were included in the study with a total of 42 patients. Both preoperative and postoperative lip and nose, anthropometric measurements were taken with a ruler and caliper. Difference between cleft and noncleft sides for philtrum lateral height (PLH), lip height (LH), nostril floor width (NF), and nostril height (NH) were taken to represent asymmetry or the severity of deformity and categorized into a grading system representing initial severity (IS) and postoperative asymmetry (PA). Relationship between the IS and PA were analyzed. Results: All four indices were lesser for the postoperative measurements showing an improved outcome after surgery. There was a significant difference between the IS and PA for PLH (P < 0.001) and NF (P = 0.007), thereby inferring that IS grade is not symmetrical from PA for both indices measured. However, there was no statistically significant difference between the IS and PA for LH (P = 0.055) and NH (P = 0.410). Therefore, the IS and the PA for these two indices are symmetrical. A majority of patients are within the similar grade for both IS and PA for LH; 15 patients for IS and PA Grade 1 and 11 patients for IS and PA Grade 2 (n = 26). As for NH, there were 13 patients with IS and PA Grade 1 and eight patients with IS and PA Grade 2 (n = 21). Conclusion: This study determines a coherent connection between the preoperative and postoperative LH and NH asymmetry. Thus, the postoperative lip and nose height asymmetry was worse in more severe clefts compared to those with a less severe initial cleft deformity.
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Early cleft lip and palate repair: Experience of the National Orthopedic Hospital Enugu, Southeast Nigeria p. 99
Ifeanyichukwu Igwilo Onah, Chuwuemeka Patrick Okoye, Edward Bala
DOI:10.4103/jclpca.jclpca_26_18  
Background: Surgical treatment of clefts during infancy poses a challenge for the plastic surgeon and anesthetists. The timing of the procedures has been fraught with controversies with no consensus. Due to the many different treatment philosophies, the timing of treatment varies among cleft centers. Historically, anesthetic risk-related data suggest that the safe time period for surgery in this population of infants could be outlined by the rule of 10's. However, more sophisticated pediatric techniques and advances in intraoperative monitoring and pediatric anesthesia have resulted in the provision of safe general anesthesia for younger infants. This article attempts to provide an audit of the outcome and complications of cleft lip/palate repair performed earlier than the hitherto defined period. Aims/Objectives: The aims of the study were to evaluate the perioperative safety profile of early cleft lip and palate repairs and to evaluate early postoperative surgical complications. Materials and Methods: A retrospective audit of all patients that had early cleft lip and palate repair at the National Orthopedic Hospital Enugu, Nigeria, between May 2006 and May 2014. Early cleft lip and palate repairs were defined as repair done before 10 weeks and 9 months, respectively. Information was obtained from the folders of the patients and the smile train express database. The anesthetic technique was general anesthesia with endotracheal intubation and halothane as the inhalational agent. Armored tubes were used for palatal repairs. The Mohler's technique and Mulliken's technique were used for unilateral and bilateral lip repair, respectively. Intravelar veloplasty ± relaxing incisions/Bardach two-flap palatoplasty were used for palate repairs. All the procedures were carried out by one consultant plastic surgeon. Results: Four hundred and ninety-three cleft-related surgeries were performed in the period. Forty-one were early cleft lip/palate repairs. Thirty-one of these early procedures were done on the lip, whereas ten procedures were on the palate. There were no mortalities. One patient (2.4%) developed anesthetic complication (prolonged recovery time). There was neither need for intra- nor postoperative transfusion. One patient had a need for supplemental oxygen therapy beyond 1 h. There was no need to take any patient back to theater. The most common early complications following lip and palate repairs were wound dehiscence and palatal fistulae, respectively. Conclusion/Recommendation: These procedures can be safely carried out when performed early. The surgical complication rates appear to be few following early procedures. Further study on long-term cleft repair on facial growth and speech needed.
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Oral health status of patients seeking therapeutic and rehabilitative care for cleft lip and cleft palate at specialty hospitals in vadodara p. 104
Ricky Pal Singh, CG Ajithkrishnan, Thanveer Kalantharkath, Amrita Pawar, Harshal Bafna, Pulkit Kalyan, Avnish Singh
DOI:10.4103/jclpca.jclpca_35_18  
Aim: To assess the oral health status of the patients seeking therapeutic and rehabilitative care for cleft lip and cleft palate at specialty hospitals of Vadodara district, Gujarat. Objectives: Record the Oral Health Status of the patients undergoing therapeutic and rehabilitative care for cleft lip and cleft palate or both by using WHO 2004 methodology. Material and Methods: A descriptive cross sectional survey was conducted at the three specialty centers of Vadodara district for a period of six months. All the subjects with cleft lip and cleft palate reporting to the OPD of these Centre were examined. Total 52 subjects reporting to these Centre were included and the data was recorded according to the Multi-centric Oral health survey-2004. The data related to oral health status was recorded, compiled, tabulated and was subjected to statistical analysis using SPSS package. Results: Among the 52 subjects examined, 32 were males and 20 were females. All the subjects had dental caries, gingival bleeding was seen in 71.1% of subjects and pockets were seen in 67.30%. Loss of attachment was seen in 96.65% of the subjects. Mean caries experience was more in males 5.78±1.18 as compared to females, whereas gingival bleeding was more in females. 19.23% of the subjects had ulcerations, 50% had abnormality of the upper lips and 15.38% had very mild fluorosis. Conclusion: In general, cleft lip and/or palate subjects exhibited poor oral health status with a higher level of caries experience and poor periodontal condition.
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The effect of dynaCleft® on presurgical orthopedics in bilateral cleft lip and palate patients p. 110
Lauren N Carlson, LaQuia A Vinson, Brian J Sanders, James E Jones
DOI:10.4103/jclpca.jclpca_6_19  
Aims: The aim of this study was to determine the effects DynaCleft® has on patients with bilateral cleft lip and palate. Subjects and Methods: Comparative data were collected from a total of 46 infants diagnosed with bilateral cleft lip and palate between 1981 and 2017. Twenty-three infants were treated with DynaCleft® and an obturator and 23 infants received an obturator only. Maxillary impressions were taken at each infant's initial clinic visit and again on the day of his/her surgical cleft lip repair. Differences in maxillary retraction, sagittal repositioning, and cleft widths were compared between the two groups. Statistical Analysis Used: Paired t-tests were used to determine if there was significant change before and after DynaCleft® therapy, and two-sample t-tests were used to compare the data between the two study groups. Results: Clinically, DynaCleft® averaged more maxillary retraction and cleft size reduction on both the right and left sides compared to the control group. Within the DynaCleft® group, a statistically significant difference was found for premaxillary retraction on both the right and left sides. However, all the other comparisons between the two groups were not found to be statistically significant. Conclusions: DynaCleft® as a presurgical orthopedic therapy may help to limit uncontrolled physiological changes and reposition the premaxillary segment, while reducing cleft widths prior to definitive lip surgery.
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Maternal factor effect on the infants with cleft lip and cleft palate: A case–control study p. 114
Majid Purabdollah, Mahnaz Sanaeeifar, Shahin Alipoor, Ahad Bahrami, Hasan Saadati, Mehdi Mokhtari
DOI:10.4103/jclpca.jclpca_21_18  
Objectives: Oral clefts are the most common congenital abnormalities that have various causes. The aim of this study was to investigate maternal factors influencing the event of this disease among newborns. Methods: This study was a case–control research. To investigate the effects of maternal factors on cleft lip and palate, medical records of 26 infants with cleft lip and palate as well as those of 52 healthy infants without this abnormality born in Qamar Bani Hashem Hospital in Khoy during 2015–2017 were studied. The required data were collected through interviews and reviewing their medical records. Results: The odds ratio of having a baby with cleft lip and cleft palate among mothers with a history of using cosmetics, being at a high age, use of psychiatric drugs, passive smoking, family history of the disease, and use of analgesics were, respectively, 1/9 (confidence interval [CI] =1.03–4.2), 2/2 (CI = 1.01–4.1), 1/7 (CI = 1.1–4.8), 2/08 (CI = 1.2–5.1), 2/8 (CI = 1.3–5.2), and 1/5 (CI = 1.01–4.9) times as much as the mothers of healthy infants. Conclusion: Lifestyle modification is the important factor in the prevention of cleft lip and cleft palate. Inclusion of preventive programs in prenatal maternal care programs may prevent or reduce the incidence of this disease.
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CASE REPORTS Top

Prevention of oronasal fistula in primary palatoplasty with acellular dermal matrix p. 120
Adrian Sanchez Balado, Maria Teresa Fernandez Diez, Mauricio Fernando Umaña Ordoñez, Elena Lorda Barraguer
DOI:10.4103/jclpca.jclpca_7_19  
Palatal fistula after primary palatoplasty remains one of the most difficult complications that plastic surgeons have to face. Once the fistula has developed, the complexity of the reconstruction increases significantly, and the revisional surgery results are not promising. The recent use of acellular dermal matrix (ADM) provides a new perspective for the reconstructive surgeon. Our goal is to reduce and prevent the postoperative oronasal fistula in patients with cleft palate by placing an ADM in the zone 3 and 4 of Pittsburgh (hard palate and hard–soft palate junction), creating an extra layer for support of the cleft palate. Seven children diagnosed of palatal cleft with high risk of developing oronasal fistula were operated. The technique of choice was two-flap palatoplasty with lateral incisions and intravelar veloplasty and three-layered closure with ADM in the hard palate and hard–soft palate junction. One patient developed a 3-mm oronasal fistula at 3-month follow-up, with spontaneous closure at 12 months. The rest of the children had an uneventful evolution. Our rate of postoperative oronasal fistula was 0% at 12 months. The use of ADM in primary palatoplasty had been of great use to prevent complications in high-risk oronasal fistula patients.
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Prominent premaxilla management on bilateral cleft lip and palate p. 124
Tatiana Izchel Castillo Torres, María Luisa Peralta Pedrero, Juan Arturo Cuellar Dodd, Cristhian Alexis Lara Robledo, Mónica Dominguez Martìnez
DOI:10.4103/jclpca.jclpca_11_19  
The treatment cleft lip and palate (CLP) should start at an early age with a multidisciplinary team and with a comprehensive approach. The aim of the management of protruded premaxilla in patients with bilateral CLP is to relocate the premaxilla to achieve surgical closure of the lip. The objective of the case report is to present the surgical-orthodontic treatment for the surgical reposition of the protruded premaxilla in a 3-year-old patient with BCLP. A patient of 3 years old with BCLP his treatment plan is a surgical reposition of the premaxilla and posterior closure of the primary lip. The surgical reposition of the premaxilla was made planning the osteotomy with dental casts. After 6 months of starting the surgical-orthodontic treatment, the patient meets bilateral lip closure satisfactorily without reported complications. Planning of the treatment allows performing a procedure that reduces the likelihood of complications and achieving the closing of the lip to reestablish the function, anatomy, and esthetics.
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LETTER TO THE EDITOR Top

To assess the prevalence of dental caries and to evaluate the oral health-related quality of life in cleft lip and palate patient p. 129
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/jclpca.jclpca_3_19  
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